Notice of Privacy Practices for Protected Health Information

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), Carolinas Pathology Group, P.A. (“CPG”) is required by law to maintain the privacy of health information that identifies you, referred to as protected health information (“PHI”), to provide you with notice of our legal duties and privacy practices regarding PHI, and to notify affected individuals following a breach of unsecured PHI.

CPG’s Use and Disclosures of PHI:

CPG is permitted to use and disclose PHI for purposes of treatment, payment, and health care operations.PHI includes the information we create and obtain in providing our services to you.Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment.It also includes billing documents for those services.

The following are examples of how CPG may use and disclose PHI about you:

For Treatment:

A nurse obtains treatment information about you and records it in a health record.

During the course of your treatment, the CPG physician determines he/she will need to consult with your primary care doctor to plan your treatment and follow-up care.He/she will share the information with such primary care doctor and obtain his/her input.

For Payment:

CPG may submit requests for payment to your health insurance company.The health insurance company (or other business associate helping us obtain payment) requests information from us regarding medical care given.We will provide information to them about you and the care given.

For Health Care Operations:

We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance.We may share information about you with such insurers or other business associates as necessary to obtain these services as part of CPG’s health care operations.

Other Disclosures and Uses

Notification - Unless you object, we may use or disclose your PHI to notify, or assist in notifying a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Business Associates – We may disclose PHI to our business associates to perform certain business functions or provide certain business services to CPG.For example, we may use another company to perform billing services on our behalf.All of our business associates are required to maintain the privacy and confidentiality of your PHI.In addition, at the request of your health care providers or health plan, CPG may disclose PHI to their business associates for purposes of performing business functions or health care services on their behalf.For example, we may disclose PHI to a business associate of Medicare for purposes of medical necessity review and audit.

Appointment Reminders – We may use and disclose PHI to remind you that you have an appointment with us.

Communication with Family - Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency.

Research - We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.

Disaster Relief - We may use and disclose your PHI to assist in disaster relief efforts.

Funeral Directors or Coroners - We may disclose your PHI to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.

Organ Procurement Organizations - Consistent with applicable law, we may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Treatment Alternatives - We may contact you to provide you with information about treatment alternatives.

Food and Drug Administration (FDA) - If you are seeking compensation through Workers Compensation, we may disclose your PHI to the extent necessary to comply with laws relating to Workers Compensation.

Public Health - As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Abuse or Neglect - We may disclose your PHI to public authorities as allowed by law to report abuse or neglect.

Correctional Institutions - If you are an inmate of a correctional institution, we may disclose to the institution or its agents the PHI necessary for your health and the health and safety of other individuals.

Law Enforcement - We may disclose your PHI for law enforcement purposes as required by law, such as when required by a court order, subpoena or other lawful process or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.

As Required by Law – CPG must disclose your PHI if required to do so by federal, state or local law.

Public Health - Federal law allows us to release your PHI to appropriate public health authorities for public health activities.

Judicial/Administrative Proceedings - We may disclose your PHI in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.

Serious Threat to Health or Safety - To avert a serious threat to health or safety, we may disclose your PHI consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

For Specialized Governmental Functions - We may disclose your PHI for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Other Uses of Your PHI that Require Your Authorization -Uses and disclosures of your PHI that involve the release of psychotherapy notes (if any), marketing, sale of your PHI, or other uses and disclosures not described in this notice or required by law will be made only with your separate written permission.If you give us permission to use or disclose PHI about you, you may revoke that permission, in writing, at any time.If you revoke your permission, we will no longer use or disclose PHI about you for the reasons covered by your written authorization.You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.

Your Health Information Rights

Although the health and billing records we maintain are the physical property of CPG, you have a right to:

Request Limits on Uses and Disclosures of Your PHI – You have the right to request that we limit: 1) how we use and disclose your PHI for treatment, payment, and health care operations activities.You also have the right to request a limit of our disclosure of PHI to individuals involved in your care or payment for your case, such as a family member or friend.CPG will consider your request, but it is not required to agree to it unless the requested restriction involves a disclosure that is not required by law to a health plan for payment or health care operations purposes and not for treatment, and you have paid for the service in full out of pocket. If we agree to a restriction on other types of disclosures, we will state the agreed restrictions in writing and will abide by them, except in emergency situations when the disclosure is for purposes of treatment.

Request Confidential Communications – You have the right to request that CPG communicate with you about your PHI at an alternative address or by an alternative means.CPG will accommodate reasonable requests.

See and Receive Copies of Your PHI – You generally have the right to inspect and obtain a copy of PHI that may be used to make decisions about your care or payment for your care.For PHI for which you have a right of access, you have the right to access and receive your PHI in an electronic format if it is readily producible in such format, and to direct CPG to transmit a copy to an entity or person you designate, provided such designation is clear, conspicuous and specific.

Request an Amendment – If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information by making a request in writing that explains the reason for the requested amendment.You have the right to request an amendment for as long as the information is kept for or by us.We may you’re your request for an amendment; if this occurs, you will be notified of the reason for denial.

Obtain an accounting of disclosures by CPG of your PHI as required to be maintained by law by delivering a written request to our office.An accounting will not include internal uses of information for treatment, payment, or health care operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care.Subject to the foregoing, if you request an accounting, the list of disclosures will include disclosures made in the six-year period prior to the date on which we receive your request, unless you request a shorter period of disclosure;

Appeal a denial of access to your PHI except in certain circumstances;

Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office/hospital using the form we provide to you upon request(The physician or other health care provider is not required to make such amendments);

File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your PHI;

Request that communications of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office/hospital using the form we give you upon request; and

Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office/hospital.

If you want to exercise any of the above rights, please contact the CPG Privacy Officer at (704) 973-5500, in person or in writing, during normal hours.This person will provide you with assistance on the steps to take to exercise your right.

You have the right to review this Notice before signing the consent authorizing use and disclosure of your PHI for treatment, payment and health care operations purposes.

Our Responsibilities - CPG is required to:

Maintain the privacy of your health information as required by law;

Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;

Abide by the terms of this Notice;

Notify you if we cannot accommodate a requested restriction or request; and

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the PHI information we maintain.If our information practices change, we will amend our Notice.You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice” or by visiting our office and picking up a copy.

To Request Information or File a Complaint:

If you have questions, would like additional information, or want to report a problem regarding the handling or your information, you may contact [insert name, title, and telephone number of internal contact person].

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to [list internal staff member].You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services.

We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the office/hospital.

We cannot, and will not, retaliate against you for filing a complaint with Secretary of Health and Human Services.

Changes to this Notice – CPG reserves the right to make changes to this notice and to its privacy policies from time to time.Such changes will apply to any PHI maintained by CPG about you.Copies of any revised notice will be available on our website at www.carolinaspathology.com and will be provided to you upon your next visit to our offices after the effective date of the changes.